Article

OIG Targets Medicaid Pediatric Dental Services

March 27, 2014

For those who have been avoiding the headlines recently, big brother is on patrol and targeting healthcare providers generally, and specifically -

As a prime example of specific oversight, yesterday the Office of the Inspector General released the results of its "Questionable Billing for Medicaid Pediatric Dental Services in New York" report, available here. OIG looked at 719 general dentists who provided services to 50 or more Medicaid children during 2012, servicing 119,102 children. Separately, OIG looked at 165 orthodontists who provided services to 50 or more Medicaid children during 2012, servicing 83, 894 Medicaid children. OIG reported in its review it identified 23 general dentists and 6 orthodontists as “extreme outliers” – representing 3% of dental providers reviewed – received extremely high payments per child ($13.2 million total for all paid by Medicaid); provided an extremely large number of services per child; or provided certain selected services, such as pulpotomoies or extractions, to an extremely high proportion of children. For more details on OIG's findings and areas of concern for pediatric dentists and orthodontists, we encourage you to read OIG's report here - http://oig.hhs.gov/oei/reports/oei-02-12-00330.pdf.

Why is the Federal government reviewing a state run benefit dental services plan? "Medicaid is the primary source of dental coverage for children in low-income families and provides access to dental care for approximately 35 million children. In recent years, a number of dentists and dental chains have been prosecuted for providing unnecessary dental procedures to Medicaid children, as well as for causing harm to children while performing these procedures." And, while state managed, the funds are federal.

What this means for you,as a general dentist or orthodontist - By recommendation of the Federal government, "the New York State Department of Health [is instructed to] (1) continue to monitor general dentists and orthodontists to identify patterns of questionable billing, (2) ensure that the State employs adequate safeguards to monitor general dentists and orthodontists under managed care, and (3) ensure appropriate followup on the general dentists and orthodontists identified as having questionable billing." So, scrutiny will likely expand as related to Medicaid reimbursable dental services. NYS will not jeopardize its funding by failing to monitor Medicaid funds. You may see a request for pre-payment records from Medicaid or request for audit post-payment.

as another license designee - oversight is not specific to one license designation. We have entered a new realm of transparency and oversight whereby records are a click away and tracking compliance is a simpler problem to solve.

Recommendations - do not wait for your number to be called. Treat compliance as preventative medicine and work towards better documentation and record keeping. Only you can keep big brother out of your practice!

ALWAYS REMEMBER - IF YOU ARE CONTACTED BY PHONE OR IN PERSON BY A GOVERNMENT AGENCY, DO NOT ENGAGE DIRECTLY - CONTACT OUR OFFICE IMMEDIATELY - make sure to get the agent's name and phone number before hanging up or requesting the individual leave the practice!